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SAN JOAQUIN LOCAL, HEALTH DISTRICT - <br /> FOk OFFICE USE 1601 E. Hazelton Ave. , '.Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin : <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Al <br /> JOB ADDRESS/LOCATION C 3 al © �f /ll 1 .�5 CENSUS TRACT <br /> Owner's Name 4: El. J Phone 71/ F " <br /> Address Cit <br /> Y ��Ca C <br /> Contractor's Name on a� ;� ' License #/ z (1_ hone'zV <br /> F" <br /> zv- <br /> TYPE OF WORK (Check) : NEW WELLjT-_<EEPEN /_/, RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _,;�gestic/private Drilled Dia., of Well Casing <br /> Domestic/public Driven Gauge of Casing j <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection __4_,j1otary Type of Grout <br /> Disposal - Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractors <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPT.REPAIR:- / / State Work Done <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San, Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on- a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting .the. well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN FINAL INSPECTION. - -- <br /> SIGNED TITLE ® <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE$II/j1gNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,.DATE 3 -) L ?i' <br /> �n J <br /> (� 1 <br />�•H 1426 Rev. 1-7 �f.77 - <br />